Provider Demographics
NPI:1063412476
Name:HOFFMAN, GLENN JOHN (DC)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:JOHN
Last Name:HOFFMAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 S RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-3938
Mailing Address - Country:US
Mailing Address - Phone:920-498-3611
Mailing Address - Fax:920-498-3611
Practice Address - Street 1:1841 S RIDGE RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-3938
Practice Address - Country:US
Practice Address - Phone:920-498-3611
Practice Address - Fax:920-498-3611
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1698-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI75-600Medicare ID - Type Unspecified
WIT62231Medicare UPIN